Date of Application School Year

Child's Name   
Mother's Name
Mother's Home Phone Mother's Work Phone:
Father's Name
Father's Home Phone Father's Work Phone:

 
Address:

E- mail
Street
City   State Zip
Child's Date of Birth  Male Female

Please tell us about your child:

Please check programs of interest:
All of our programs run Monday through Thursday

1st Choice:   Monday-Thursday Mornings (8:30-11:30) Monday-Thursday Afternoons (12:30-3:30) Extended Day (8:30-3:30)    

2nd Choice: Monday-Thursday Mornings (8:30-11:30) Monday-Thursday Afternoons (12:30-3:30) Extended Day (8:30-3:30)   

3rd Choice: Monday-Thursday Mornings (8:30-11:30) Monday-Thursday Afternoons (12:30-3:30) Extended Day (8:30-3:30)
         

Family information (please complete each box):
1.  What was your child's birth weight?    
2.   How many members are in your household?   
3.  What is your annual household income? (required)
4.  Is any parent/guardian unemployed?    Yes No
5.  Do any parents/guardians attend school or
participate in job training programs?    Yes No
6.  If yes, where and how many credits?   
7.  Are you a single parent?    Yes No
8.  Has your child lost a parent to death or divorce?    Yes No
9.  Has your child lost a sibling due to death?    Yes No
10.  Were you a teenager when your first child was born?    Yes No
11.  Does your child have a chronically ill/handicapped parent or sibling? Yes No
12.  Is either parent incarcerated?    Yes No
13.  Do you live in a rural or segregated area?    Yes No
14.  Does your child have a nutritional deficiency?    Yes No
15.  Does your child have a long term or chronic illness?    Yes No
16.  Does your child have a diagnosed handicap condition?    Yes No
17.  Does your child have a language deficiency?    Yes No
18.  Does your child have a destructive or violent temper?    Yes No
19.  Has your child had a lack of stable support system
(moved a lot, parent in and out of the home, etc.)?    Yes No
20.  Does either parent/guardian have a substance abuse
or addiction problem?   Yes No
21.  Does either parent/guardian have a family history
of low school achievement?    Yes No
22.  Does either parent/guardian have a family history
of delinquency (trouble with law)?    Yes No
23.  Does either parent/guardian have a family history
of diagnosed family problems?    Yes No
24.  Has your child been the victim of sexual or physical abuse?    Yes No
25.  What is the primary language spoken in the home?   

Please enter any additional comments that you think will help
us decide what program best fits your child's needs: